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Headache - assessment - Management
How do I diagnose the less common causes of headache?
- Exclude symptoms of serious secondary causes and other secondary causes of headache, and tension-type headache and migraine, before considering less common causes of headache. Ask about:
- Duration, frequency, and any diurnal pattern.
- Location — unilateral, bilateral, or localized to areas of the face or scalp.
- Intensity and character.
- Association with ipsilateral autonomic features, including:
- Conjunctival injection or lacrimation.
- Eyelid oedema.
- Miosis or ptosis.
- Nasal congestion or rhinorrhoea.
- Forehead and facial sweating.
- Episodic unilateral facial pain (in areas supplied by one or more divisions of the trigeminal nerve), lasting a few seconds to 2 minutes, is diagnosed as:
- Trigeminal neuralgia when it is sharp, stabbing, intense in character, and triggered by a trivial stimulus, such as light touch. It usually affects the cheek and chin.
- Episodic unilateral headache that is severe and orbital, supraorbital, or temporal is diagnosed as:
- Cluster headache when:
- Severe pain lasts between 15 minutes and 3 hours, and is associated with intense restlessness and agitation, and may be triggered within 90 minutes of drinking alcohol.
- Episodes occur between one every other day and eight-times daily, often waking the person at night.
- At least five episodes of pain have occurred.
- The headaches are associated with at least one ipsilateral autonomic feature.
- Paroxysmal hemicrania when:
- Pain lasts between 2 minutes and 30 minutes.
- Episodes occur more than five times a day more than half of the time, although periods with lower frequency may occur.
- At least 20 episodes of pain have occurred.
- Pain responds completely to therapeutic doses of indometacin.
- Associated with at least one ipsilateral autonomic feature.
- Persistent unilateral headache is diagnosed as:
- Hemicrania continua when it is a moderate-intensity headache with severe exacerbations and is:
- Associated with at least one ipsilateral autonomic feature, other than facial sweating or eyelid oedema.
- Unremitting, and has lasted for more than 3 months.
- Completely responsive to therapeutic doses of indometacin.
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